KNEE PAIN QUESTIONNAIRE

KNEE PAIN: (If you have pain on only one side, you can skip questions related to the other side.)

What side is your pain on?

Left Right Bilateral. If Bilateral: Equal Left greater than Right Right greater than Left
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How long have you had knee problems?
Left knee:
Please specify how many days, weeks, months, or years:_____________________
If injured, what was the date of injury? _____________________
Right knee:
Please specify how many days, weeks, months, or years:_____________________
If injured, what was the date of injury? _____________________
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How severe is your pain? (Circle one.) 0 is no pain and 10 is worst pain of your life.
Left knee:
SCALE OF PAIN: 0 – 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10
Right knee:
SCALE OF PAIN: 0 – 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10
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Where do you feel your knee pain? (Mark all that apply or describe it yourself on the blank line provided)
Left knee: _________________________________
No pain Front of knee Inner side of the knee - medial Outer side of the knee - lateral
Entire knee Back of the knee Above knee cap Under knee cap
Right knee: _________________________________
No pain Front of knee Inner side of the knee - medial Outer side of the knee - lateral
Entire knee Back of the knee Above knee cap Under knee cap
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What does the pain feel like? (Mark all that apply or describe it yourself on the blank line provided)
Left knee: _________________________________
Dull Achy Sharp A baseline dull and achiness with episodes of sharp pain
Throbbing Burning Stabbing Crampy
Right knee: _________________________________
Dull Achy Sharp A baseline dull and achiness with episodes of sharp pain
Throbbing Burning Stabbing Crampy
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Does the pain radiate? Yes / No. If yes, where does it radiate to? (Mark all that apply or describe it yourself)
Left knee: _________________________________
Knee to hip To the ankle Into foot Into the toes Into back of knee
Down outer leg Down inner leg Down back of leg to knee Down back of leg to foot
Right knee: _________________________________
Knee to hip To the ankle Into foot Into the toes Into back of knee
Down outer leg Down inner leg Down back of leg to knee Down back of leg to foot
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Do you have swelling?
Left knee: _________________________________
None Mild Moderate Severe Intermittent Initially present, but resolved
Right knee: _________________________________
None Mild Moderate Severe Intermittent Initially present, but resolved
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Pain is aggravated by: (Mark all that apply or describe it yourself on the blank line provided)
Left knee: _________________________________
Ascending stairs Descending stairs Arising from a chair Kneeling or squatting Going from sit-to-stand
Walking Exercise In/out of a car Bending the knee Twisting Pivoting Sitting for long periods of time
Right knee: _________________________________
Ascending stairs Descending stairs Arising from a chair Kneeling or squatting Going from sit-to-stand
Walking Exercise In/out of a car Bending the knee Twisting Pivoting Sitting for long periods of time
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Pain is relieved by: (Mark all that apply or describe it yourself on the blank line provided)
Left knee: _________________________________
Rest Sitting Standing Lying down Stretching Extending the knee
Pain medications Topical ointments Topical patches Ice Heat Nothing
Right knee: _________________________________
Rest Sitting Standing Lying down Stretching Extending the knee
Pain medications Topical ointments Topical patches Ice Heat Nothing
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Associated symptoms?
Left knee: _________________________________
None Clicking Popping Locking Catching
Right knee: _________________________________
None Clicking Popping Locking Catching
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How does your knee pain affect your ability to walk?
Left knee: _________________________________
No difficulty Slight Mild Moderate Marked/serious limitations
Only walks around the house Totally disabled, wheelchair bound
Right knee: _________________________________
No difficulty Slight Mild Moderate Marked/serious limitations
Only walks around the house Totally disabled, wheelchair bound
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How far can you walk without stopping because of your knee pain?
Left knee: _________________________________
Unlimited > 6 blocks (30 mins) 2-3 blocks (10-15 minutes) < 1 block Indoors only Bed to chair
Right knee: _________________________________
Unlimited > 6 blocks (30 mins) 2-3 blocks (10-15 minutes) < 1 block Indoors only Bed to chair
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Do you need support when walking?
None Cane for long walks Cane full time One crutch
Two canes Two crutches Walker Unable to walk / wheelchair
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What have you tried to improve your knee pain?
Weight loss NSAIDs Tramadol Tylenol Physical therapy Brace Ice Heat
Cane/Walker Glucosamine Cortisone injections Other: ___________________________________
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If you’ve had an injection in the involved joint, how many have you had?
Left knee:
None One Two Three Other: _________. When was the last one injection? ______________________
Right knee:
None One Two Three Other: _________. When was the last one injection? ______________________
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Do you experience knee pain at rest?
Left knee:
None Mild Moderate Severe
Right knee:
None Mild Moderate Severe
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Does your knee pain interfere with sleeping? Yes / No
Have you ever had a DVT (deep vein thrombosis)? Yes / No
Have you ever had a PE (pulmonary embolism? Yes / No
Do you have any history of bleeding or clotting disorders? Yes / No
Has anyone in your immediate family had a DVT or PE? Yes / No
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Current living arrangements:
I live alone in a house or apartment
I live in a house or apartment with my spouse/relatives or other(s)
I live in a nursing home or residential health care facility
Other: ________________________________________________________________________________________
Do you have stairs in your home/apartment? Yes / No. If yes, how many? _________________________________

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Previous Surgery on ___________? (mm/yyyy) Type of Surgery and Name of Surgeon
Left knee: YES NO _______________________ _____________________________________________
Right knee: YES NO _______________________ _____________________________________________
Left hip: YES NO _______________________ _____________________________________________
Right hip: YES NO _______________________ _____________________________________________
Previous infection ____________?
Left knee: YES NO Left hip: YES NO Other: ______________________________________
Right knee: YES NO Right hip: YES NO
Other types of surgery? Date of Surgery (mm/yyyy)
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